Achilles tendon pain

Achilles tendon pain is one of the more common sporting injuries seen by our Physiotherapy team.

A typical history for an Achilles injury is a runner, usually around 35-55 years, who gradually felt a soreness on one or both Achilles tendons in the early stages of a run. It gets worse as it lasts longer in the run and aches afterwards, even when walking.

Many people are concerned about a torn Achilles but this is the least common cause. And it’s worth noting that Achilles pain is very rarely a precursor to a ruptured Achilles.

Achilles tendon ruptures happen without warning, not as a result of worsening Achilles tendon pain.

Achilles pain diagnosis

Gradual onset pain

The majority of Achilles diagnoses are for gradually worsening tendon pain. These are tendinopathies, previously referred to as “Achilles tendonitis”, and come in a few different varieties.

As mentioned above, the pain often starts in a subtle way, just noticeable at the start of one run or one morning on waking. The symptoms gradually increase and last longer until it’s there for most of the day and throughout every run.

This may be due to a simple irritation of the tendon substance. It reacts by becoming painful on loading but there’s no structural change associated with this injury.

Alternatively it may be due to breakdown of the tendon material, referred to as a degenerative tendon, which will then cause pain on loading.

Both types of injury are treated in a similar fashion but with slightly different timeframes for recovery and need for ongoing prevention.

It should be noted that these injuries are not inflammatory so anti-inflammatory medication doesn’t work. Also worth noting that unlike most tendons, the Achilles tendon doesn’t have a sheath around it. So it can’t get many of the other tendon conditions that we see elsewhere in the body (such as tenosynovitis).

Acute (sudden) onset pain

There’s a separate group of injuries that occur as a result of a single incident of overload. Often you’re running along and your heel unexpectedly drops into a pothole. Or you’re standing still and suddenly try to sprint with max force.

For this type of onset, there’s a risk of an Achilles tendon tear. Most tears only affect a small portion of the tendon but require imaging (ultrasound or MRI) to confirm the magnitude of the damage.

Achilles tendon rupture can also occur but it’s associated with a VERY loud popping noise and distinct reaction (“who the hell just shot me in the calf?” – aka the sniper reaction).

Achilles injury rehab

Achilles tendon rehab is actually quite similar for minor tendon tears and tendinopathies. The focus is on providing enough stimulus for the tendon quality to improve without causing overload.

These guidelines should help you map out a rehab plan.

Mild symptoms are OK during your rehab exercises and training

Worsening pain is not OK

Sharp pain is not OK

Strong pain is not OK

Exercising every day is better than every 2nd day

When the current exercises don’t challenge you or generate soreness, progress your tendon loading

Loading can be progressed in three ways but typically only advance one of these parameters at a time

Running on flat at easy pace for 50% of regular run distance (swap for brisk walk for non-runners or if running is too painful) – provides gentle bouncing action for tendon, maintains running efficiency, improves mental state

Next progression (no set timeframe – progress when symptoms ease on first phase exercises)

Calf bounce exercises – leaning against a wall and bouncing gently in a small movement, on one leg or two depending on symptoms and strength